View Answer

D

10. A 35-year-old man is involved in a high-speed motor vehicle collision. He arrives in the emergency room in respiratory distress. Radiographs taken during the initial evaluation reveal an air-fluid level in the left chest. Management includes all of the following except

A Establishment of a secure airway

B Immediate placement of a nasogastric tube

C Urgent thoracotomy to repair the injury

D Placement of adequate peripheral vascular access

E Urgent laparotomy to repair injury

View Answer

C

11. Which of the following forms of congenital heart disease is most common?

A Transposition of the great vessels

B Tetralogy of Fallot

C Atrial septal defect

D Patent ductus arteriosus

E Ventricular septal defect

View Answer

E

12. A 32-year-old man is referred for a 1.0-cm lesion of the right upper lobe of the lung. The lesion appears calcified. Previous chest radiograph taken 1 year prior demonstrates the lesion to be present at the same size. Further workup and treatment would include which of the following?

A CT scan–guided biopsy

B Radiation therapy

C Surgical excision

D Antibiotics

E Observation with repeat chest x-ray

View Answer

E

13. A 57-year-old male patient with a 60 pack-year smoking history is referred for a 1.5-cm solitary mass in the right upper lobe. CT scan demonstrates no evidence of lymph node involvement. What should further workup or treatment include?

A Radiation therapy

B Open lung biopsy

C Chemotherapy

D Right upper lobectomy

E Repeat chest x-ray in 6 months

View Answer

D

14. A 22-year-old female is referred for evaluation of a 2-cm posterior mediastinal mass discovered on routine chest radiograph. What is the most likely diagnosis?

A Bronchogenic cyst

B Lymphoma

C Neurogenic tumor

D Thymoma

E Adenocarcinoma

View Answer

C

15. A 78-year-old previously healthy man is admitted to the emergency department complaining of angina, dyspnea, and near syncope. Electrocardiogram is normal, and a loud systolic murmur is heard in the second right interspace with radiation to the carotids. What is the most likely diagnosis in this patient?

A Myocardial infarction

B Pericarditis

C Mitral regurgitation

D Aortic stenosis

E Aortic insufficiency

View Answer

D

16. Which of the following is not a risk factor for coronary artery disease?

A Hypertension

B Smoking

C Diabetes

D Renal failure

E Hypercholesterolemia

View Answer

D

17. A 72-year-old female patient is admitted with unstable angina. Cardiac catheterization reveals severe triple-vessel coronary artery disease. The optimal treatment of this patient would include which of the following?

A Coronary artery bypass surgery

B Observation

C Medical management (nitrates, β-blockers)

D Coronary angioplasty

E Tissue plasminogen activator

View Answer

A

18. A 72-year-old patient with a history of syncope and dyspnea presents for evaluation for peripheral vascular surgery. Physical examination reveals a systolic crescendo–decrescendo murmur that radiates to the carotid arteries. As he is symptomatic, his diseased valve would typically have an area of less than which of the following?

A 1 cm²

B 1.5 cm²

C 2 cm²

D 3 cm²

E 4 cm²

View Answer

A

19. A 29-year-old man is evaluated for a cerebral vascular accident. Physical examination reveals a systolic ejection murmur at the left second interspace and a fixed split second heart sound. What is the most likely diagnosis?

A Ventricular septal defect

B Atrial septal defect

C Mitral stenosis

D Aortic insufficiency

E Ventricular aneurysm

View Answer

B

Answers and Explanations

• 1. The answer is C [Chapter 4, II A 2]. Hypotension, diminished breath sounds, and tracheal deviation are clinical signs of tension pneumothorax. This represents a surgical emergency and without treatment may rapidly become fatal. In this scenario, prompt needle decompression of the left chest is indicated, prior to chest x-ray or other diagnostic studies that could delay treatment.

• 2. The answer is D [Chapter 4, I B 3 c]. Insertion of a left chest tube will most likely improve the patient's condition. The pleura of the lung lies immediately adjacent to the scalene fat pad. If the pleura is injured during scalene node biopsy, a resultant pneumothorax can cause the symptoms that developed in the patient described. Scalene node biopsy can also injure other nearby structures; for example, lymph duct structures, the brachial plexus, the vagus and phrenic nerves, and the subclavian vessels, resulting in corresponding symptoms.

A large wound hematoma could cause tracheal compression and airway compromise, but this is not described. Intubation with positive pressure ventilation will make the pneumothorax worse without a chest tube. While injury to the subclavian vessels could cause a hemothorax, a chest tube still needs to be inserted for evaluation. A pneumothorax is the more likely injury. With a suspected left-sided pneumothorax, a subclavian line should be inserted on the left because of the risk of producing a second right-sided pneumothorax.

• 3. The answer is C [Chapter 4, II A 2 b–c]. The patient has signs and symptoms consistent with a tension pneumothorax. This life-threatening situation should be treated immediately by needle thoracentesis. A chest tube insertion should follow this maneuver. A chest radiograph is not necessary to confirm the diagnosis and will only delay treatment. Local wound exploration has no role in the management of stab wounds of the chest. Pericardiocentesis is the choice when evidence indicates pericardial tamponade.

• 4. The answer is E [Chapter 5, II B]. Indications for definitive surgical management of spontaneous pneumothorax include recurrence (ipsilateral or contralateral), persistent air leak greater than 7–10 days, and incomplete expansion of lung.

• 5–6. The answers are 5-D [Chapter 4, II A 5, 6; B 1, 2, 5, 6] and 6-B [Chapter 4, II A 6]. Causes for the chest radiograph and electrocardiographic findings are multiple and include aortic rupture, cardiac tamponade, tracheobronchial disruption, hypoxia, and cardiac contusion. A more precise diagnosis would be mandatory before undertaking thoracotomy because operative strategy would depend on which injury is present.

Blunt thoracic trauma with or without flail chest results in chest wall muscle damage and pain, with resultant splinting and loss of chest wall elasticity. Intra-alveolar hemorrhage and interstitial edema reduce pulmonary parenchymal elasticity. Therefore, both lung and chest wall compliance decrease. PCO₂, A-a gradient, and shunt fractions would probably be elevated, and ventricular contractions would probably be decreased.

• 7–8. The answers are 7-C [Chapter 5, II B 2] and 8-B [Chapter 5, II C 2–3]. The patient developing a pleural effusion in the setting of an underlying pneumonia requires thoracentesis for diagnosis. The character of the fluid described is consistent with that present in an empyema. Initial treatment of an empyema should involve closed chest tube drainage. Thoracotomy and decortication or rib resection may be required when the empyema is not adequately drained by the chest tube or is otherwise not amenable to closed drainage. Video-assisted thorascopic surgery pleurodesis is not standard treatment for an empyema.

• 9. The answer is D [Chapter 5, IV B 5]. The patient has a solitary pulmonary nodule. He is older than age 40, and the characteristics do not favor a benign lesion, such as concentric calcification. In addition, the lesion was not present on the chest radiograph 5 years earlier. Diagnosis is mandatory for determining whether the lesion is malignant. This can be done by needle biopsy or thoracoscopic biopsy.

• 10. The answer is C [Chapter 4, II B]. This patient is presenting with a diaphragmatic disruption, as evidenced by the identification of the stomach in the chest. Treatment involves standard resuscitation principles, (Airway, Breathing, Circulation), placement of a nasogastric tube to prevent acute gastric dilitation (which can produce severe, life-threatening respiratory distress), and urgent transabdominal repair of the diaphragmatic defect. If diagnosis is delayed by 7–10 days, transthoracic repair is preferred to facilitate the freeing of any adhesions to the lung.

• 11. The answer is E [Chapter 6, II A]. The most common forms of congenital heart disease are, in decreasing order: ventral septal defect, transposition of the great vessels, tetralogy of Fallot, hypoplastic left heart syndrome, atrial septal defect, and patent ductus arteriosus.

• 12. The answer is E [Chapter 5, IV B]. Isolated lung nodules less than 1.0 cm are known as coin lesions. Workup should include a detailed history, noting any use of tobacco products or previous malignancy. Any prior chest radiographs should be obtained. A calcified lesion that has not enlarged over a 2-year period suggests a benign process. In this patient, observation with follow-up x-ray is indicated. Any change in the lesion is an indication for biopsy.

• 13. The answer is D [Chapter 5, V F]. The appropriate treatment is surgical lobectomy. Observation with repeat chest x-ray is not warranted with a smoking history.

This patient is in clinical stage I, based on tumor size and nodal status. There is no clear benefit in biopsying the lesion. Chemotherapy and radiation may be indicated in certain stage IIIa lesions or in locally advanced disease.

• 14. The answer is C [Chapter 5, X C]. The most common posterior mediastinal mass is a neurogenic tumor. Seventy-five percent of neurogenic tumors occur in children under 4 years of age. Childhood tumors are more likely to be malignant. Lymphoma, thymoma, and germ cell tumors are commonly located in the anterior mediastimun. Middle mediastinal lesions include bronchogenic and pericardial cysts. Metastatic adenocarcinoma may involve the pleural surfaces; however, lesions are often small and multiple.

• 15. The answer is D [Chapter 6, I B]. Angina, syncope, and dyspnea are the classic symptoms of aortic stenosis. Physical examination generally reveals a systolic ejection murmur in the second right intercostal space. An electrocardiogram and serial cardiac enzymes should be obtained to rule out cardiac ischemia. The murmur of aortic insufficiency is diastolic with a clinical picture of heart failure.

• 16. The answer is D [Chapter 6, I E]. Risk factors for coronary artery disease are the same as those for vascular disease in general––smoking, diabetes, obesity, hypertension, and hypercholesterolemia. While renal failure is often associated with coronary artery disease, this is because of the frequent association with other risk factors, such as hypertension and diabetes.

• 17. The answer is A [Chapter 6, I E]. This patient has severe triple-vessel coronary disease. Studies have shown a significant survival advantage for patients in this category who are treated with surgical revascularization, rather than with medical management or angioplasty. Additional benefit may be realized in patients with compromised ventricular function.

• 18. The answer is A [Chapter 6, I B]. This patient has aortic stenosis. Symptoms usually begin when the valve area is less than 1 cm².

• 19. The answer is B [Chapter 6, II D]. Echocardiogram searching for thrombus or septal defect should be obtained in a younger patient who suffers from a cerebral vascular accident. A second interspace murmur and fixed splitting of the second heart sound are classic findings in atrial septal defect. Anticoagulation for 4–6 weeks with elective repair of the atrial septal defect is the indicated treatment.

Study Questions for Part III(vascular)

Directions: Each of the numbered items in this section is followed by several possible answers. Select the ONE lettered answer that is BEST in each case.

1. A 65-year-old woman with a long history of atrial fibrillation presents to the emergency department with a history of sudden onset of severe, constant abdominal pain. After the onset of pain, she vomited once and had a large bowel movement. No flatus has been passed since that time. Physical examination reveals a mildly distended abdomen, which is diffusely tender, although peritoneal signs are absent. Ten years ago, she underwent an abdominal hysterectomy. What is the most likely diagnosis in this patient?

A Acute cholecystitis

B Perforated duodenal ulcer

C Acute diverticulitis

D Acute embolic mesenteric ischemia

E Small bowel obstruction secondary to adhesions